Failure to Prevent and Investigate Falls and Implement Safety Interventions
Penalty
Summary
The facility failed to properly de-escalate a resident prior to transfer, conduct a thorough investigation to determine the root cause of an incident, and implement interventions to prevent further events for two residents reviewed for falls. One resident with a history of hemiplegia, dementia with agitation, and other significant medical conditions experienced a fall and became combative during the transfer back to bed. Staff did not utilize de-escalation interventions outlined in the care plan, such as using extra caution during manual transfers, offering to call family for support, or using a lifting device. As a result, the resident sustained multiple skin tears, and the facility did not complete a comprehensive investigation to determine whether the injuries occurred during the fall or the transfer. Another resident, who was cognitively intact and had multiple diagnoses including Parkinson's disease and osteoporosis, experienced a fall resulting in a fractured patella. The facility failed to document the fall in the resident's medical record, did not perform a head-to-toe assessment, and did not ensure required notifications were made. Additionally, a care plan intervention to place a "Call, don't fall" sign in the resident's room was not implemented, and staff were unaware of any new interventions following the fall. Interviews with staff and review of records confirmed that required procedures for investigating incidents, updating care plans, and implementing safety interventions were not followed. The lack of documentation, incomplete investigations, and failure to implement care plan interventions contributed to the deficiencies identified for both residents.